I'm stressed & fat
A 30 year old female with history of uncontrolled asthma presents with fatigue, weight gain, depression, changes to her periods. On exam, patient is hypertensive, has central obesity, a buffalo hump, prominent abdominal striae, and facial hair. What is the most likely diagnosis?
Cushing! (uncontrolled asthma - likely takes lots of steroids when flaring)
Syndrome: Excess cortisol (exogenous most likely)
Disease: Increased ACTH secretion
Dx: 24-hr urine cortisol + serum ACTH
What is the difference between type 1 and type 2 diabetes mellitus?
Type 1: autoimmune destruction of beta cells in islets of Langerhans
Type 2: insulin insensitivity related to high levels of glucose/insulin over time +/- predisposing factors
A 40-year-old woman presents with fatigue, dry hair, constipation, weight gain, and poor memory. What is the most likely diagnosis?
Hypothyroidism
*middle aged woman with ALL the symptoms
A breastfeeding G2P2 24 year old mom presents with 1 day history of right breast pain and some chills. On exam, patient is febrile and right breast is tender, warm, swollen, erythematous, and indurated. You suspect mastitis. How are you going to treat?
Encourage her to keep breastfeeding! Warm/cool compresses, anti-inflammatories for the pain
22 year old female presents with unilateral pelvic pain. You suspect she has an ovarian cyst.
What is the most common type? What causes it?
Follicular: occurs when follicle fails to rupture and continues to grow
Second most common: corpus luteum - occurs when the corpus luteum fails to degenerate after ovulation
What are common side effects of statins?
What is the worst one?
How do you monitor?
Myalgias, GI upset, elevated LFTs
Serious: Rhabdomyolysis! Myositis, liver toxicity, hepatitis
Monitor: LFTs and CK (at start, after 3 months, annually + with myalgias)
An otherwise healthy patient presents with excessive urination and thirst. A comprehensive metabolic panel is normal. Urinalysis is significant for a low specific gravity, no other findings.
What test are you going to order?
What is the most likely diagnosis and how are you gone manage?
Diabetes insipidus is a disorder of antidiuretic hormone (ADH) function, either production and release (central) or action (nephrogenic).
Order: a fluid deprivation test or desmopressin stimulation test
Management:
Central - desmopression (ADH)
Nephrogenic: refer (won't respond to ADH)
What is the most common cause of hypothyroidism and hyperthyroidism respectively?
Hypothyroid: Hashimoto (autoimmune)
others - iodine deficiency, postpartum thyroiditis, radiation, medications
Hyperthyroidism: Graves (autoimmune)
others - toxic multi-nodular goiter, TSH secreting adenoma, excess intake, iatrogenic
What is the most common type of breast cancer and risk factors?
Type: Infiltrative ductal carcinoma (75%); associated with axillary lymphatic metastasis
Risk factors: female, increasing age, hx of breast cancer, family hx of breast cancer, radiation to chest, obesity, early menarche, late menopause, birth of first bb after 35 or nulliparity, HRT, EtOH, smoking, BRCA 1, BRCA 2, PALB2, CheK2
What is the most common type of ovarian cancer? What are risk factors? What level do you measure?
Type: Epithelial (90%)
Risk factors: Family history!, increased # of ovulatory cycles (early menarche, late menopause, nulliparity), caucasians, genetic disorders (Peutzz-Jehgers, Turners, Lynch syndrome)
Level: CA-125 *careful when using because uterine fibroids, PCOS, and endometriosis can elevate CA-125*
A 44-year-old woman presents to the office with worsening fatigue and dizziness over the past few months. She decided to make an appointment because she had a few near fainting episodes at her indoor office job. After reviewing her chart, you note that she has lost about 15 pounds over the past year. Upon physical exam, you note that she has a blood pressure of 86/62 mm Hg and that she has areas of hyperpigmentation to her face, arms, hands and mucous membranes. What is the most likely diagnosis and how are you going to confirm?
Addisons (Adrenal Insufficiency)
Diagnosis: Cortisol level (morning serum)
ACTH to confirm
Treatment: some 'roids
You just diagnosed some dude with diabetes. Give me some complications of this disease, pretty please.
Most common: Retinopathy, Nephropathy, Peripheral neuropathy
Others: Autonomic neuropathy (gastroparesis), cerebrovascular accidents, nec fasc, gangrene, sepsis, candida/opportunistic infections, acanthosis nigricans
What is the finding associated with subacute and what will the labs look like?
Bonus: what are the names of T3 and T4?
Painful! thyroid caused by neutrophilic inflammation
Labs: technically; depend on stage - but when patient is in PAIN
Decreased TSH, increased T3/T4, elevated ESR and leukocytosis
T3 triiodothyronine, T4 thyroxine :)
What is the most common type of endometrial cancer and risk factors for endometrial cancer?
How will your patient present?
Type: Adenocarcinoma (80%)
Risk factors: elderly, nulliparity, diabetes, obesity, menstrual irregularity, estrogen mono-therapy, hypertension
Presentation: Post-menopausal bleeding! -> EMB
You think your patient has PCOS. According to the Rotterdam criteria, what is required for diagnosis?
2 out of 3
- Oligo- or anovulation (or both)
- clinical or biochemical signs of hyperandrogenism (or both)
- Polycystic ovaries (u/s)
A 22 year old, thin, male patient presents with waxy, yellow plaques at the corners of his eyes.
What are these called?
What is a possible diagnosis and what level is expected?
Xanthomas
Chylomicronemia (cause he is young, thin)
TG: >800 (markedly elevated)
Tell me how to diagnose type 2 diabetes (all the ways)
Symptoms + random glucose > 200
Fasting glucose> 126 on 2 separate occasions
Plasma glucose > 200 2 hrs after GTT (75g)
HgbA1c > 6.5%
I'm just going to give you labs cause I'm a bully. No symptoms. What is the diagnosis?
TSH: Low
T3: High
T4: High
Anti-thyrotropin receptor antibodies: present
Graves disease (hyperthyroid + autoimmune)
Anti-thyrotropin receptor antibodies: Graves’
Anti-thyroid peroxidase autoantibodies: Hashimoto’s
Anti-thryoglobulin autoantibodies: Hashimoto’s
What do you tell her?
She has fibrocytic breasts (most common benign breast disorder)
These are just fluid filled cysts/fibroids due to an exaggerated response to hormones.
You encourage her to be familiar with HER breasts (self breast awareness). Warm/cool compresses if achy. OCPs if interested.
Inform her of option of u/s to confirm diagnosis and reassure her. Mammogram at 40 is appropriate.
Your patient was having some right sided pelvic pain so you ordered an u/s. The ultrasound identifies a cystic mass with a densely echogenic tubercle containing containing hair, teeth, and fat.
What the heCK is that and how are you going to fix it???
That there's a teratoma (germ cell tumor)
Managment: cut it OUt
Complications: ovarian torsion, rupture, malignant transformation
A 42 year old diabetic female presents with LDL of 138 and an estimated ASCVD risk of 9%. What type of therapy are you going to initiate?
*I don't think you need to memorize the statin benefit groups yet* when in doubt - use a high one (LDL lowering >50%)
Moderate Intensity Statin (LDL lowering 30-49%)
Example: Atorvastin 10mg, Rosuvastatin 10mg, Simvastatin 20mg
Tell me some differences between HHS and DKA :)
HHS: days to weeks, glucose 600-1200, pH normal, potassium/bicarb normal, more common in Type 2, profound neurologic changes, higher mortality
DKA: rapid onset, glucose 350-900, acidic pH, decreased bicarb, elevated K, more common in Type 1, drowsiness/AMS, less fatal
A 60-year-old lady with a hx of Hashimotos' presents with altered mental status. She is hypothermic, hypotensive, and bradycardic. Puffiness in the hands and face, a thickened nose, swollen lips, and a fat thyroid are noted on physical exam.
How are you going to manage her? Is she going to be ok?
Dx: Myxedema Coma!
Supportive (airway, rewarming, consult endo)
Hydrocortisone + IV Levothyroxine (t4) +/- IV triiodothyronine (t3) *rarely*
she might be ok; high mortality
Your patient presents with a red, swollen, warm, itchy breast with edema and dimpling/pitting.
What is the most likely diagnosis? What is the name of the skin changes seen above? What is the prognosis?
Inflammatory breast cancer
Rare and aggressive
Skin dimpling/edema: Peau d'orange
Prognosis: Not the hottest
A 26-year-old woman presents to your office for an infertility consult. She and her husband have been trying to conceive for the past three years but have been unsuccessful. Upon questioning, she says that her menstrual cycles are very irregular, sometimes as long as two to three months may pass between periods. Upon examination, you notice that she has facial acne, facial hair, and is overweight with a BMI of 30.
How are you going to manage this patient?
Weight loss (first line)
Combo Oral Contraceptives to induce regular menses and antagonizes endometrial proliferation -> reduce androgen levels -> suppress FSH/LH release
Clomiphene citrate for return of ovulation once trial is done
Spironolactone: for hirsutism (can't use cause trying to get pregnant)
Metformin: may improve menstruation regularity